[104-10222-10042.pdf — page 152]
# 14-0000024. REFERENCES: List three persons living in the United States or Territories of the United States who are NOT related to you and who have definite knowledge of your character, qualifications, and fitness for the position for which you are applying. Include repeat names of supervisors listed under Item 16 (EXPERIENCE)| FULL NAME               | (Give complete current address, including street and number) | BUSINESS OR OCCUPATION || ----------------------- | ------------------------------------------------------------ | ---------------------- || 1. Mr. John Lewis       | Oakwood High School, Dayton 9, O.                            | Principal              || 2. Miss Theadosia Moran | Cazanovia R. D. 2, N. Y.                                     | Teacher                || 3. Mr. Harry Schwartz   | Univ. of Syracuse, Syracuse, N. Y.                           | Professor              |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | YES | NO  || ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | :-: | :-: || 25. MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER REGARDING YOUR CHARACTER QUALIFICATIONS?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |  X  |     || 26. ARE YOU A CITIZEN OF OR DO YOU OWE ALLEGIANCE TO THE UNITED STATES?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |  X  |     || 27. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY U.S.A. OR ANY COMMUNIST ORGANIZATION?                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |     |  X  || 28. ARE YOU NOW, OR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |     |  X  || 29. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY ORGANIZATION ASSOCIATION MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH ADVOCATES THE OVERTHROW (BY FORCE OR VIOLENCE) OF THE CONSTITUTIONAL FORM OF GOVERNMENT, OR ORGANIZATION, ASSOCIATION MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH HAS ADOPTED A POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES, OR OF SEEKING TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS? |     |     || If your answer to question 27, 28, or 29 above is "yes," state in Item 39 the names of all such organizations, associations, movements, groups, or combination of persons and dates of membership. Give complete details of your activities therein and make any explanation you desire regarding your membership or activities therein.                                                                                                                                                                                                                                       |     |     || 30. SINCE YOUR 16TH BIRTHDAY, HAVE YOU EVER BEEN ARRESTED, INDICTED OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING OR CITED, FINED OR IMPRISONED OR PLACED ON PROBATION OR HAVE YOU EVER BEEN REQUIRED TO DEPOSIT BAIL ON COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR ORDINANCE (EXCLUDING MINOR TRAFFIC VIOLATIONS FOR WHICH A FINE OR FORFEITURE OF $25 OR LESS WAS IMPOSED)?                                                                                                                                                              |     |     || If your answer is "Yes," list all such cases under Item 39 below. Give in each case (1) the date, (2) the nature of the offense or violation, (3) the name and location of the court, (4) the penalty imposed, if any, or other disposition of the case & if finger-prints will be taken.                                                                                                                                                                                                                                                                                      |     |     || 31. HAVE YOU EVER BEEN DISCHARGED OR ASKED TO RESIGN FROM ANY POSITION BECAUSE OF INCOMPETENCE OR UNSATISFACTORY CONDUCT?                                                                                                                                                                                                                                                                                                                                                                                                                                                      |     |     || If your answer is "Yes," give in Item 39 the name and address of employer, date, and reasons in each case.                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |     |     || 32. HAVE YOU EVER BEEN BARRED FROM TAKING A CIVIL SERVICE COMMISSION EXAMINATION OF APPOINTING CIVIL SERVICE APPOINTMENT?                                                                                                                                                                                                                                                                                                                                                                                                                                                      |     |     || If your answer is "Yes" give dates of and reasons for such debarment in Item 39.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |     |     || 33. HAVE YOU ANY PHYSICAL HANDICAP, DISEASE, OR OTHER DISABILITY WHICH SHOULD BE CONSIDERED IN ASSIGNING YOU TO WORK?.                                                                                                                                                                                                                                                                                                                                                                                                                                                         |     |     || If your answer is "Yes," give complete details in Item 39 so that consideration can be given to your physical fitness for the job.                                                                                                                                                                                                                                                                                                                                                                                                                                             |     |     || 34. DO YOU RECEIVE AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE?                                                                                                                                                                                                                                                                                                                                                                                           |     |     || If your answer is "Yes," give complete details in Item 39.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |     |     |INDICATE "YES" OR "NO" ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                 | YES | NO  || ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | :-: | :-: || 35. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY OR MUNICIPALITY?                                                                                                            |     |  X  || If your answer to "Yes," give details in Item 39.                                                                                                                                               |     |     || 36. DOES THE UNITED STATES GOVERNMENT EMPLOY IN A CIVILIAN CAPACITY ANY RELATIVE OF YOURS (BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 24 MONTHS?                    |     |     || If your answer is "Yes," show in Item 39 for EACH such relative: (1) full name; (2) present address; (3) relationship; (4) Department of Agency by which employed, and (5) kind of appointment. |     |     |### SPECIAL INSTRUCTIONS FOR CLAIMING VETERAN PREFERENCEA. If you are claiming preference as a PEACETIME VETERAN who has been awarded a campaign badge or service ribbon, or as a DISABLED VETERAN, or as the WIFE OF A DISABLED VETERAN, or as the WIDOW OF A WAR OR CAMPAIGN VETERAN, attach Veteran Preference Claim, CSC Form 14, together with proofs required therein.B. If you are a WAR-TIME VETERAN not claiming disability preference you should NOT submit your discharge with this application. Preference will be tentatively credited to you if appointed, you will be required to submit to the appointing officer prior to entry on duty, official evidence of separation from active service in the armed forces of the United States in time of war.|                                                                                                                                                       | YES | NO  || ----------------------------------------------------------------------------------------------------------------------------------------------------- | :-: | :-: || 37. (A) WERE YOU EVER IN THE UNITED STATES MILITARY OR NAVAL SERVICE DURING TIME OF WAR?                                                              |     |  X  || (B) IS THE WORD "HONORABLE" OR THE WORD "SATISFACTORY" USED IN YOUR DISCHARGE OR SEPARATION PAPERS TO SHOW THE TYPE OF YOUR DISCHARGE OR SEPARATION?. |     |     || (C) WAS SERVICE PERFORMED ON AN ACTIVE FULL-TIME BASIS, WITH FULL MILITARY PAY AND ALLOWANCE?                                                         |     |  X  |DATE OF ENTRY OR ENTRIES INTO SERVICEDATE OF SEPARATION OR SEPARATIONSBRANCH OF SERVICE (Army, Navy, Marine Corps, Coast Guard, etc.)SERIAL # (if none, give grade of rating at time of separation).|                                                                                                                                            | YES | NO  || ------------------------------------------------------------------------------------------------------------------------------------------ | :-: | :-: || 38. IF YOU SERVED IN THE UNITED STATES MILITARY OR NAVAL SERVICE DURING WAR, DID YOU EARN AND RECEIVE A CAMPAIGN DEVICE OR SERVICE RIBBON? |     |     || 39. ARE YOU A DISABLED VETERAN?                                                                                                            |     |  X  || If so, and you have not listed your disability in answer to Item 33, explain in Item 39 below.                                             |     |     || 40. ARE YOU A VETERAN WHO HAS NOT REMARRIED?.                                                                                              |     |     || 41. ARE YOU THE WIFE OF A VETERAN WHO HAS A SERVICE-CONNECTED DISABILITY?                                                                  |     |     |THIS SPACE FOR USE OF APPOINTING OFFICER ONLYThe information contained in the answers to Question 37 above has been verified by comparison with the discharge certificate on ........................................................., 19........SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS (Indicate item numbers to which answers apply)If more space is required, use paper the same size as this page. Write on each sheet your name, address, date of birth, and examination title. Attach to inside of this application.Before signing this application check back over it to make sure that you have answered ALL questions correctly.I CERTIFY that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.False statement on this application is punishable by Law (U. S. Code., Title 18, Section 80)SIGNATURE OF APPLICANT Mess Charlotte L Zehmer(INK name; e.g., initials and surname if former name "Miss Mary L. Doe")